Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events among High-Risk Ward Patients.

OBJECTIVE: Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized. Therefore, we aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review. DESIGN: Multicenter retrospective observational study. SETTING: Inpatient medical-surgical wards at four health systems from 2006-2020 PATIENTS: Randomly selected patients (1,000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage (eCART), were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected. Of the 4,000 included patients, 2,484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n=1,021), followed by arrhythmia (19%; n=473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest x-rays (42%), and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%), and antiarrhythmics (19%). CONCLUSIONS: We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration. KEY POINTS: Question: What are the most common diagnoses, diagnostic test orders, and treatments for ward patients experiencing clinical deterioration? Findings: In manual chart review of 2,484 encounters with deterioration across four health systems, we found that sepsis was the most common cause of clinical deterioration, followed by arrythmias, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic test orders, while antimicrobials and fluid boluses were the most common treatments. Meaning: Our results provide new insights into clinical deterioration events, which can inform institutional treatment pathways, rapid response team training, and patient care.

Accuracy of Clinicians' Ability to Predict the Need for Intensive Care Unit Readmission.

Rationale: Determining when an intensive care unit (ICU) patient is ready for discharge to the ward is a complex daily challenge for any ICU care team. Patients who experience unplanned readmissions to the ICU have increased mortality, length of stay, and cost compared with those not readmitted during their hospital stay. The accuracy of clinician prediction for ICU readmission is unknown.Objectives: To determine the accuracy of ICU physicians and nurses for predicting ICU readmissionsMethods: We conducted a prospective study in the medical ICU of an academic hospital from October 2015 to September 2017. After daily rounding for patients being transferred to the ward, ICU clinicians (nurses, residents, fellows, and attendings) were asked to report the likelihood of readmission within 48 hours (using a 1-10 scale, with 10 being "extremely likely"). The accuracy of the clinician prediction score (1-10) was assessed for all clinicians and by clinician type using sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic curve for predicting the primary outcome, which was ICU readmission within 48 hours of ICU discharge.Results: A total of 2,833 surveys was collected for 938 ICU-to-ward transfers, of which 40 (4%) were readmitted to the ICU within 48 hours of transfer. The median clinician likelihood of readmission score was 3 (interquartile range, 2-4). When physician and nurse likelihood scores were combined, the median clinician likelihood score had an AUC of 0.70 (95% confidence interval [CI], 0.62-0.78) for predicting ICU readmission within 48 hours. Nurses were significantly more accurate than interns at predicting 48-hour ICU readmission (AUC, 0.73 [95% CI, 0.64-0.82] vs. AUC, 0.60 [95% CI, 0.49-0.71]; P = 0.03). All other pairwise comparisons were not significantly different for predicting ICU readmission within 48 hours (P > 0.05 for all comparisons).Conclusions: We found that all clinicians surveyed in our ICU, regardless of the level of experience or clinician type, had only fair accuracy for predicting ICU readmission. Further research is needed to determine if clinical decision support tools would provide prognostic value above and beyond clinical judgment for determining who is ready for ICU discharge.

Creating emotional false recollections: Perceptual recombination and conceptual fluency mechanisms.

We investigated the impact of 2 hypothetical mechanisms of episodic memory reconstruction-perceptual recombination and conceptual fluency-on objectively measured recollection accuracy and false recollections of neutral and emotional stimuli. Participants encoded negative, neutral, and positive pictures depicting objects and scenes (i.e., target pictures), each accompanied with a descriptive verbal label (e.g., "boy crying at funeral," "wooden basket on floor," "four chimpanzees laughing together"). Next, they encoded fragmented pictures of some of the scenes they did and did not earlier see (perceptual misinformation), or they received multiple presentations of the corresponding verbal labels (conceptual misinformation). Recollection of target pictures was then tested, using labels as retrieval cues. We had three key findings in each of two experiments. First, as in our prior work, both perceptual and conceptual misinformation significantly increased false recollection judgments of nonstudied pictures, including high-confidence errors. These effects implicate perceptual recombination and conceptual fluency mechanisms. Second, these misinformation effects generalized across all emotional categories, implicating separable roles of these two mechanisms on emotional recollections. Finally, conceptual misinformation was less likely to influence negative than neutral recollection errors, providing new evidence that emotion can improve retrieval monitoring accuracy and reduce false memories based on conceptual fluency (i.e., an emotional distinctiveness heuristic). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Dark Side of Context: Context Reinstatement Can Distort Memory.

It is widely assumed that context reinstatement benefits memory, but our experiments revealed that context reinstatement can systematically distort memory. Participants viewed pictures of objects superimposed over scenes, and we later tested their ability to differentiate these old objects from similar new objects. Context reinstatement was manipulated by presenting objects on the reinstated or switched scene at test. Not only did context reinstatement increase correct recognition of old objects, but it also consistently increased incorrect recognition of similar objects as old ones. This false recognition effect was robust, as it was found in several experiments, occurred after both immediate and delayed testing, and persisted with high confidence even after participants were warned to avoid the distorting effects of context. To explain this memory illusion, we propose that context reinstatement increases the likelihood of confusing conceptual and perceptual information, potentially in medial temporal brain regions that integrate this information.